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THE MASTERY COMPANY
PO Box 1806
Woodinville, WA 98072

info@masterycompany.com

: General Registration - Dental Practice Assessment Tools

This is the general registration form for Mastery's dental practice assessment tools. First, check those assessments you wish to subscribe to. Then, complete the form and CLICK SUBMIT at the bottom of the page. Upon completion of registration, you will be linked to a brief assessment that allows us to customize your survey process and reports.

Each of the Core, Dentist Performance and Practice Management survey instruments come with a Report of Findings and a 1-hour phone debrief with Dr. Marc Cooper who will review your results and coach you on implementation of the recommendations.

The Staff Performance Evaluations come as a package. There is a single fee per practice for up to eight employees and additional fees for staff evals beyond eight.

If you have any questions, please feel free to e-mail us at Mastery Information or call (425) 806-8830.

NOTE: If you are a Repeat User, please follow this link to register for more assessments.

Check the Core Practice Assessment tool(s) you are registering for:

Staff Satisfaction Assessment
Patient Satisfaction Survey OR Parent-Patient Satisfaction Survey
Mastery Referral Index (MRI)
Study Club Package (NEW)

Check the Dentist Performance Evaluation(s) you are registering for:

Dentist Performance Evaluation
Associate Performance Evaluation
Partnership Performance Evaluation

Check the Staff Performance Evaluation(s) you are registering for:

Hygienist Receptionist Dental Assistant
Treatment Coordinator Office Manager

Check the Practice Management Assessment tool(s) you are registering for:

Regulatory Compliance
Chart Review
Referral Satisfaction for Dental Specialists

How were you referred to Mastery Surveys? *

Name (Last, First) *

E-Mail Address *

Office Address: *

Zip Code:

Country

Main Phone Number *

Back Line Number *

Note to Dentist Subscriber:
If you intend to delegate any of the management of the selected survey(s) to someone else in your office, please complete the following section. We will copy this individual on all communications and he or she will be used as your point of contact to assist us with the survey process.

Name (First, Last)

Title

E-mail Address

Direct Phone Line

COPYRIGHT NOTICE: This survey may be downloaded for viewing purposes, but may not be used without the prior consent of THE MASTERY COMPANY (TMC). Consent may be obtained by registration with or by hiring TMC to conduct the survey. Use of this questionnaire without prior consent is in violation of the Federal Copyright Law [17 USC 101 et seq]. Violators may be subject to criminal penalties as well as liability for substantial monetary damages, including statutory damages of up to $100,000 per infringement, costs and attorney's fees.

Copyright 2005-2010, THE MASTERY COMPANY. All Rights Reserved.

Agreement to Conditions: *

Yes, I agree.

No.

Credit Card Information

Credit Card Number (No Spaces) *

Expiration Date (01/02)

* Required to submit this form